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Depression: Major Depression & Unipolar Varieties
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Antidepressants for Major Depression - With Children, TCAs, and MAOIs

Rashmi Nemade, Ph.D., Natalie Staats Reiss, Ph.D., and Mark Dombeck, Ph.D.

A Note Concerning Children, Antidepressants and Suicide Risk

In 2004, the FDA issued a Public Health Advisory warning the public about the increased risk of suicidal thoughts and behavior in children and adolescents being treated with antidepressant medications. This warning was based on clinical trials conducted with five SSRIs (Celexa, Prozac, Luvox, Paxil and Zoloft) and four SNRIs (Wellbutrin, Remeron, Serzone and Effexor XR). However, a 2007 article published by the Journal of the American Medical Association suggests that the risks of antidepressant use in children and adolescents may be lower than previously reported by the FDA, and that potential benefits of the medications outweigh possible risks. Prozac is currently the only medication approved to treat depression in children under age 12.

Tricyclic Antidepressants (TCAs)

Although the Tricyclic Antidepressants are the oldest antidepressants on the market, they are typically second or third choice treatments. Because of the long list of side effects associated with this family of medication, including weight gain, sedation, visual disturbances (e.g., problems focusing), anxiety, and sexual dysfunction, there is little interest in further research or development of TCAs. In addition, these medications are potentially toxic at high levels, making them particularly problematic from an overdose perspective. Blood monitoring of medication levels is sometimes used to help ensure that therapeutic (helpful) rather than toxic (harmful) blood levels are maintained. Not surprisingly, the tricyclic medications are today mostly used when other newer medications have failed. Some common TCAs are imipramine (Tofranil) and maprotiline (Ludiomil).

Monoamine Oxidase Inhibitors (MAOIs)

Monoamine oxidases are enzymes that break down serotonin, norepinephrine, and dopamine. By preventing these enzymes from working, MAOI medications allow neurotransmitters to remain in the synaptic gap longer, which gives them more opportunity to activate the post-synaptic neuron's receptors, creating greater stimulation of the post-synaptic recipient neuron. Increasing someone's serotonin, norepinephrine, and/or dopamine levels tends to have an antidepressant effect.

The side effects of MAOIs include: insomnia, sleepiness, nervousness, low blood pressure, sweating, weight gain, and sexual dysfunction. In addition, MAOIs can cause dangerous interactions with certain foods and beverages that contain a high level of tyramine, such as many cheeses, pickled foods, chocolates, certain meats, beer and wine. Foods and beverages containing tyramine interact with MAOIs and can cause a dangerously high increase in blood pressure, which can lead to a stroke. Because of the complications associated with MAOIs, these medications are considered second choices for treating depression. Some common MAOIs are isocarboxazid (Marplan), moclobemide (Aurorix), and phenelzine (Nardil).

Other Antidepressants

There are many other substances used for their antidepressant effects such as lithium, Omega-3 fatty acids, stimulants, thyroid replacement therapies, herbal remedies, and alternative medicines such as Traditional Chinese Medicine, Ayurveda, and Homeopathy. However, further research is necessary to validate many of these treatments. In addition, these therapies are not without their own side effects and should always be taken under the supervision of a physician.